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Guías Manejo TEC Grave - 3º Edición, 2019
Guías Manejo TEC Grave - 3º Edición, 2019
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Ake N. Grenvik Professor of Critical Care Medicine, Vice Chair, Depart- 14
Professor & Vice Chair Strategic Affairs, Anesthesiology & Pain Medi-
ment of Critical Care Medicine, Professor of Anesthesiology, Pediatrics, cine, Professor, Pediatrics, Director, Harborview Injury Prevention and
Bioengineering, and Clinical and Translational Science, Director, Safar Research Center (HIPRC), University of Washington, Seattle, WA.
Center for Resuscitation Research, University of Pittsburgh School of Herman and Faye Sarkowsky Endowed Chair, Head, Division of Pediatric Neu-
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Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA. rology, University of Washington, Seattle Children’s Hospital, Seattle, WA.
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Department of Neurology and Department of Anesthesiology, Critical Any opinions, findings, and conclusions or recommendations expressed in
Care and Pain Medicine, Boston Children's Hospital, Harvard Medical this material are those of the authors and do not necessarily reflect the views
School, Boston, MA. of the U.S. Army Contracting Command, Aberdeen Proving Ground, Natick
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Professor, Pacific Northwest Evidence-based Practice Center, Depart- Contracting Division, Stanford University, or the Brain Trauma Foundation.
ment of Medical Informatics and Clinical Epidemiology, Oregon Health & The information contained in the Guidelines for the Management of Pediat-
Science University, Portland, OR. ric Severe Traumatic Brain Injury reflects the current state of knowledge at
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Associate Professor, Pacific Northwest Evidence-based Practice Cen- the time of publication. The Brain Trauma Foundation, American Association
ter, Department of Medical Informatics and Clinical Epidemiology, Ore- of Neurologic Surgeons, Congress of Neurologic Surgeons, and other col-
gon Health & Science University, Portland OR. laborating organizations are not engaged in rendering professional medical
services and assume no responsibility for patient outcomes resulting from
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Diane and Bruce Halle Endowed Chair in Pediatric Neurosciences,
application of these general recommendations in specific patient circum-
Chief, Pediatric Neurosurgery, Director, BARROW Neurological Insti-
stances. Accordingly, the Brain Trauma Foundation, American Association
tute at Phoenix Children’s Hospital, Phoenix, AZ.
of Neurologic Surgeons, and Congress of Neurologic Surgeons consider
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Chair, Department of Neurological Surgery, Oregon Health & Science adherence to these clinical practice guidelines will not necessarily assure
University, Portland, OR. a successful medical outcome. The information contained in these guide-
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Research Associate, Pacific Northwest Evidence-based Practice Cen- lines reflects published scientific evidence at the time of completion of the
ter, Department of Medical Informatics and Clinical Epidemiology, Ore- guidelines and cannot anticipate subsequent findings and/or additional
gon Health & Science University, Portland OR. evidence and therefore should not be considered inclusive of all proper
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Research Assistant, Pacific Northwest Evidence-based Practice Center, procedures and tests or exclusive of other procedures and tests that are
Department of Medical Informatics and Clinical Epidemiology, Oregon reasonably directed to obtaining the same result. Medical advice and deci-
Health & Science University, Portland OR. sions are appropriately made only by a competent and licensed physician
who must make decisions in light of all the facts and circumstances in each
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Professor and Chief, Critical Care Medicine, Children’s National Medical individual and particular case and on the basis of availability of resources
Center, Washington, DC. and expertise. Guidelines are not intended to supplant physician judgment
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Emeritus Professor of Pediatrics, University of Utah, Salt Lake City, UT. with respect to particular patients or special clinical situations and are not a
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Department of Neurosurgery, Stanford University, Stanford, CA. substitute for physician-patient consultation. Accordingly, the Brain Trauma
Foundation, American Association of Neurologic Surgeons, and Congress
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Department of Pediatrics, British Columbia’s Children’s Hospital, Clini- of Neurologic Surgeons consider adherence to these guidelines to be
cal Investigator, Child and Family Research Institute, University of British
voluntary, with the ultimate determination regarding their application to be
Columbia, Vancouver, BC. Canada.
made by the physician in light of each patient’s individual circumstances.
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School of Nursing/School of Medicine, Department of Pediatrics, Divi-
Supported, in part, by the U.S. Army Contracting Command, Aberdeen
sion of Pediatric Critical Care Medicine, Duke University, Durham, NC.
Proving Ground, Natick Contracting Division, through a contract awarded
Copyright © 2019 by the Society of Critical Care Medicine and the World to Stanford University (W911 QY-14-C-0086) and a subcontract awarded
Federation of Pediatric Intensive and Critical Care Societies to Oregon Health & Science University. Prior editions were supported, in
DOI: 10.1097/PCC.0000000000001736 part, by funding from multiple sources through the Brain Trauma Foundation.
Dr. Kochanek received funding from the Society of Critical Care Medicine Edition published in 2012 (2). This new publication is part of
(Editor-in-Chief of Pediatric Critical Care Medicine), from serving as an
expert witness on cases in pediatric critical care. Drs. Carney and Tot-
an effort to update a suite of three Brain Trauma Foundation
ten’s, Ms. Davis-O’Reilly’s, and Ms. Hart’s institutions received funding Guidelines, including similar acute care guidelines for adults
from Stanford University. Dr. Selden disclosed that he has stock options (published in January 2017) (3) and guidelines for prehos-
(current $0 value) in Cerebrotech for scientific advisory board service
(this device is not clinically available and is not referenced in the work).
pital management of all ages (forthcoming). It represents a
Dr. Reuter-Rice received funding from textbook royalties and curriculum substantial effort by a multidisciplinary group of individuals
content, and she received support for article research from Robert Wood assembled to reflect the team approach to the treatment of
Johnson Foundation funding 2013–2016. Dr. Wainwright received fund-
ing from Sage Therapeutics. The remaining authors have disclosed that
these complex, critically ill patients that is essential to optimiz-
they do not have any potential conflicts of interest. ing critical care and improving outcomes.
This executive summary has been co-published and appears in Pediatric A total of 48 new studies were included in this Third Edition.
Critical Care Medicine and Neurosurgery. Although some progress has been made and should be celebrated,
For information regarding this article, E-mail: kochanekpm@ccm.upmc.edu overall the level of evidence informing these Guidelines remains
low. High-quality randomized studies that could support level
I recommendations remain absent; the available evidence pro-
Objectives: The purpose of this work is to identify and synthesize duced only three level II recommendations, whereas most rec-
research produced since the second edition of these Guidelines ommendations are level III, supported by lower quality evidence.
was published and incorporate new results into revised evidence- In addition to the Guidelines, we have authored a com-
based recommendations for the treatment of severe traumatic panion article that presents a “Critical Pathway” algorithm of
brain injury in pediatric patients. care for both first tier and second tier (refractory intracranial
Methods and Main Results: This document provides an overview of hypertension) approaches (4). The algorithm reflects both the
our process, lists the new research added, and includes the revised evidence-based recommendations from these Guidelines as
recommendations. Recommendations are only provided when there well as consensus-based expert opinion, vetted by the full com-
is supporting evidence. This update includes 22 recommendations, mittee, where evidence was not available. The algorithm also
nine are new or revised from previous editions. New recommenda- addresses a number of issues that are important but were not
tions on neuroimaging, hyperosmolar therapy, analgesics and seda- previously covered in the Guidelines, given the lack of research.
tives, seizure prophylaxis, temperature control/hypothermia, and Specifically, the algorithm addresses issues such as a step-wise
nutrition are provided. None are level I, three are level II, and 19 are approach to elevated intracranial pressure (ICP), differences in
level III. The Clinical Investigators responsible for these Guidelines tempo of therapy in different types of patients, scenarios with
also created a companion algorithm that supplements the recommen- a rapidly escalating need for ICP-directed therapy in the setting
dations with expert consensus where evidence is not available and of impending herniation, integration of multiple monitoring
organizes possible interventions into first and second tier utilization. targets, and other complex issues such as minimal versus opti-
The purpose of publishing the algorithm as a separate document is mal therapeutic targets and approaches to weaning therapies.
to provide guidance for clinicians while maintaining a clear distinction It is important to acknowledge that these Guidelines were writ-
between what is evidence based and what is consensus based. This ten as the Approaches and Decisions in Acute Pediatric TBI Trial
approach allows, and is intended to encourage, continued creativity (ADAPT) (5–7), one of the most important in the field of pediatric
in treatment and research where evidence is lacking. Additionally, it TBI, was coming to a close. The ADAPT completed enrollment of
allows for the use of the evidence-based recommendations as the 1,000 cases of severe pediatric TBI and is one example of the recent,
foundation for other pathways, protocols, or algorithms specific to heightened general interest in TBI as a disease. This new interest in
different organizations or environments. The complete guideline doc- the importance of TBI has emerged in part from the recognition
ument and supplemental appendices are available electronically from of the high prevalence of TBI across the injury severity spectrum,
this journal. These documents contain summaries and evaluations of particularly concussion, and from the need for new classification
all the studies considered, including those from prior editions, and systems and new trial design for TBI in both children and adults (8,
more detailed information on our methodology. 9). We expect that the results of ADAPT, along with those of other
Conclusions: New level II and level III evidence-based recommen- ongoing trials and recently completed research in the field, will help
dations and an algorithm provide additional guidance for the devel- provide new insight and clarity into the acute medical management
opment of local protocols to treat pediatric patients with severe of infants, children, and adolescents with severe TBI and support
traumatic brain injury. Our intention is to identify and institute a further refinement of the recommendations in these documents.
sustainable process to update these Guidelines as new evidence
becomes available. (Pediatr Crit Care Med 2019; 20:280–289)
Key Words: critical care; evidence-based medicine; guidelines;
THE SCOPE OF THE GUIDELINES
pediatrics; systematic review; traumatic brain injury
The Guidelines address monitoring, thresholds for ICP and
cerebral perfusion pressure (CPP), and 10 categories of treat-
ments specific to TBI in infants, children, or adolescents. The
Guidelines are not intended to cover all topics relevant to the
T
he Third Edition of the Brain Trauma Foundation’s care of patients with severe TBI. Specifically, topics related to
Guidelines for the Management of Pediatric Severe general good care for all patients, or all trauma patients, are
Traumatic Brain Injury (TBI) (1) updates the Second not included.
Developing protocols that integrate TBI-specific, evidence- recommendations. This synthesis is described for each topic
based recommendations with general best practices for trauma in the online document in the sections titled Evaluation of the
patients, and that provide guidance, suggestions, or options in Evidence, following the Recommendations and preceding the
areas of TBI management where the evidence is insufficient, is Evidence Summary.
outside the scope of these Guidelines. These recommendations Quality of the Body of Evidence. Assessing the quality of
are intended to provide the foundation on which protocols can the body of evidence involves four domains: the aggregate
be developed that are appropriate to different treatment envi- quality of the studies, the consistency of the results, whether
ronments. The algorithm developed by the clinical investigators the evidence provided is direct or indirect, and the precision
is one example of such a protocol, but not the only possible pro- of the effect estimates. The criteria and ratings are outlined in
tocol that could be developed based on these Guidelines. the Methods section of the online document and more detailed
definitions are in Appendix G (1). In addition, the number of
studies and number of included subjects are considered. Based
METHODS
on these, an overall assessment is made as to whether the qual-
The methods for developing these Guidelines were organized
ity of the body of evidence is high, moderate, low, or insuffi-
in two phases—the systematic review, including the identifica-
cient. The assessment of the body of evidence for each subtopic
tion, assessment, and synthesis of the literature; and the use of
is included in a table in each topic section in the full guideline
that foundation for evidence-based recommendations.
document.
Systematic Evidence Review and Synthesis Applicability. Applicability is the extent to which research
Literature Search and Review. Our literature search protocol findings are useful for informing recommendations for a
is described in detail, and the search strategies are in Appendix broader population (usually the population that is the target
D of the full online guideline document (1). Please note that of the recommendations). In this edition, we considered the
all appendices mentioned in this executive summary refer to applicability of individual studies in the Quality of the Body of
appendices to the full guidelines document (1). Evidence and Applicability section immediately following the
The key criteria for including studies in the review were as recommendations in the full guideline document.
follows: the population included pediatric patients (age ≤ 18
Recommendations
yr) with severe TBI (defined as Glasgow Coma Scale score of
Development of Recommendations. Classes 1, 2, and 3 stud-
3–8), and the study assessed an included outcome (mortality,
ies constitute the evidence on which the recommendations are
neurologic function, or appropriate intermediate outcomes for
based. Once evidence was identified, whether or not it could be
the topic). Two reviewers independently identified studies to
used to inform recommendations was based on the quality of
include, and differences were resolved via consensus or by a
the body of evidence and consideration of applicability. Under
third reviewer. Detailed inclusion criteria and a list of studies
our current methods, identification of evidence is necessary
excluded after full-text review are in the online document in
but not sufficient for the development of evidence-based rec-
Appendices B and E (1). This edition adds studies published
ommendations. If no evidence was identified, no recommen-
from 2010 to June 2017.
dations were made. If the identified evidence was extremely
Quality Assessment and Data Abstraction of Individual
limited (e.g., inconsistent results, imprecise), it could be con-
Studies. All included studies were assessed for potential for bias,
sidered insufficient to support a recommendation.
which is a systematic approach to assessing the internal valid-
Given this approach, there were cases in which evidence
ity or quality of studies. The quality criteria used in the second
was identified, but the quality was low and applicability con-
edition were maintained and applied to the newly identified
cerns restricted the ability to translate the evidence into rec-
studies of monitoring and treatments. The criteria for thresh-
ommendations. Even if a recommendation was not made,
old studies were revised to be specific to the quality of threshold
the studies contributing evidence were included in the full
studies. (See appendix F in the online document [1] for a com-
Guideline to acknowledge their place in the body of evidence
plete list of the quality criteria used for individual studies.) Key
and make the evidence accessible for future consideration. As
data elements were then extracted from each study and placed
new studies are generated and added to the evidence base, we
into tables. The tables were provided to the clinical investiga-
expect to see changes in the assessment of the quality of the
tors and summarized by topic in the guideline document (see
body of evidence.
summaries by topic in the full report online [1]). Class 1 is the
Level of Recommendations. Recommendations in this edi-
highest class and is limited to good-quality randomized trials.
tion are designated as level I, level II, or level III. The level of
Class 2 includes moderate-quality randomized controlled trials
recommendation is determined by the assessment of the qual-
(RCTs) and good-quality cohort or case-control studies. Class 3
ity of the body of evidence, which includes, but is not limited
is the lowest class and is given to low-quality RCTs, moderate-
to, the class of the included studies.
to low-quality cohort or case-control studies, and treatment
The levels were primarily based on the quality of the body
series and other noncomparative designs.
of evidence as follows:
Synthesis. The final phase of the evidence review is the
synthesis of individual studies into information that the 1) Level I recommendations were based on a high-quality
clinical investigators and the methods team use to develop body of evidence.
2) Level II recommendations were based on a moderate-qual- recommendations in each topic (So III.1 is the first Level III
ity body of evidence. recommendation and III.2 is the second level III recommenda-
3) Level III recommendations were based on a low-quality tion). In these tables, the recommendations in italics are new
body of evidence. or have been significantly revised, whereas those in regular text
have not changed or only have changes in wording. The online
In addition to the quality of evidence, we also considered
applicability. Currently, there is a lack of standards and devel- guideline document includes a section on each topic consist-
oped methods to assess applicability. For this reason, applica- ing of an Introduction, Recommendations, Evaluation of the
bility alone was not used to downgrade a recommendation; Evidence, and Summary of the Evidence (including evidence
however, we did include and document in the full guideline tables and a narrative overview).
any applicability issues that were identified and discussed by
the authors. Monitoring Recommendations
“Insufficient” was used in cases where the body of evidence Monitoring does not affect outcomes directly; rather the infor-
was insufficient to support a recommendation either because mation from monitoring can be used to direct treatment deci-
there were no studies identified or because the body of evi- sions. Treatment informed by data from monitoring may result
dence had major quality limitations. If the evidence was rated in better outcomes than treatment informed solely by data from
insufficient, no recommendation was made. clinical assessment. Monitoring recommendations are related
to the influence on patient outcomes of three types of moni-
toring: ICP monitoring, advanced cerebral monitoring (ACM),
REVISED RECOMMENDATIONS and neuroimaging. The recommendations for ICP and ACM
Summary of Changes to Recommendations did not change; however, two notes were added to the ACM
This update includes 22 evidence-based recommendations; recommendation. For neuroimaging, one new recommen-
nine are new or revised significantly from the previous edition. dation suggesting that CT examinations not be used to rule
There are no level I recommendations, three recommendations out the possibility of elevated ICP was added to the existing
are level II, and the remaining 19 are level III. recommendation.
Tables 1, 2, and 3 provide the recommendations for
monitoring, thresholds, and treatments, respectively. Each Threshold Recommendations
recommendation is numbered with a roman numeral for These recommendations are related to threshold values for vari-
the level followed by a period and a number counting the ables that are monitored during the in-hospital management
(Continued )
of patients with severe TBI. This includes thresholds for ICP Treatment Recommendations
and CPP. There are no changes to the recommendations from Table 3 contains the recommendations for 10 treatments
the prior edition. Additional studies that supported the exist- included in the Guidelines. These topics are included because
ing recommendations were added to the evidence tables in the they are specific to the in-hospital management of TBI or
full guideline document and are listed in Table 4. are related to risks experienced by pediatric TBI patients.
Nutrition Level II
To Improve Overall Outcomes
II.1. Use of an immune-modulating diet is not recommended.
Level III
To Improve Overall Outcomes
III.1. Initiation of early enteral nutritional support (within 72 hr from injury) is suggested to
decrease mortality and improve outcomes.
Corticosteroids Level III
To Improve Overall Outcomes
I II.1. The use of corticosteroids is not suggested to improve outcome or reduce ICP.
Note: Recommendation III.1 is not intended to circumvent use of replacement corticosteroids
for patients needing chronic steroid replacement therapy, those with adrenal suppression,
and those with injury to the hypothalamic-pituitary steroid axis.
ICP = intracranial pressure, PTS = posttraumatic seizures.
The first recommendation indicates that prophylactic hypothermia does not improve overall outcomes for pediatric patients with severe traumatic brain injury.
a
The second recommendation indicates that hypothermia is effective in control of ICP. Although this may appear to be somewhat antithetical, the two endpoints
of overall outcomes and ICP control are clearly distinct. Please see the full Guideline for additional detail.
Italics indicate new or revised recommendations.
The topics that are included reflect current practice but are filled by creating clinical protocols using consensus where
expected to change as new treatments are developed that evidence is lacking. Together the gaps and protocols provide
may replace or complement existing treatments. These top- structure and identify patient samples for the generation of
ics include 15 recommendations; of these seven are new or new research. The new research populates the evidence base
revised. These seven include two recommendations in hyper- which can then be used to further develop the Guidelines,
osmolar therapy; one in analgesics, sedatives, and neuromus- creating a recursive cycle designed to grow the evidence base
cular blockade; one in seizure prophylaxis; two in temperature and increase the number of evidence-based recommenda-
control; and one in nutrition. tions in the future.
Although the number of studies has increased in this update
of the Guidelines, most recommendations are based on a small
DISCUSSION number of studies that are mostly class 3. We hope this will
New Evidence change as the impact of evidence-based practice is documented
Table 4 lists the 35 new studies (10–46) added to the evidence and new studies undertaken. We are optimistic that the next
base that was used to support new or existing recommendations. update will have a stronger evidence base because an important
This table presents the studies by topic, provides the citation, study of pediatric TBI, designed and executed by a guidelines
and includes the studies design, the number of patients included clinical investigator and coauthor, is concluding. This study,
(n), and data class. An additional 13 new studies were added to ADAPT, was designed to address 12 a priori hypotheses across
the guideline document that addressed topics without sufficient five Guidelines topics (advanced neuromonitoring, hyperos-
evidence to support a recommendation (47–59). More details, molar therapy, cerebrospinal fluid drainage, ventilation, and
such as the outcomes and results for all new studies, are included nutrition) and is likely to also provide information on other
in the evidence tables and narrative in the full online guideline. topics and questions from post hoc analyses (5). ADAPT is an
important example of the value of a guideline in highlighting
Ongoing and Future Research what cannot be said due to lack of evidence; those gaps provide
Evidence-based guidelines rarely (if ever) contain enough opportunities for innovation and direction for research.
data to fully populate a clinical protocol. This is certainly In addition to ADAPT, the pediatric TBI community needs
the case with the treatment of severe pediatric TBI. Rather to promote and support innovate ways to generate higher qual-
the goal is to contribute to a transparent, ongoing process ity class 1 and class 2 studies that can inform stronger (i.e., level
I and level II) recommendations. These other needs include the
that leads to better research and more evidence in the future.
following:
These Guidelines provide recommendations based on the
available evidence and at the same time identify gaps that 1) Research that examines the integration of individual treat-
can inform the future research agenda. These gaps can be ments in the context of goal-directed therapy. No treatment
TABLE 4. New Studies Added Since Last Edition to Evidence Supporting Revisions to
Recommendations
Topics References Study Design and Sample Size (n) Data Class
Monitoring
Intracranial pressure Bennett et al (10) Retrospective, n = 3,084 3
monitoring Alkhoury et al (11) 3
Retrospective, n = 3,107
Bennett et al (12) Retrospective, n = 4,667 3
Advanced neuromonitoring Stippler et al (13) Treatment series, n = 46 3
Figaji et al (14) Treatment series, n = 28 3
Neuroimaging Bailey et al (15) Treatment series, n = 9 3
Bata et al (16) Retrospective, n = 71 3
Thresholds
Thresholds for treatment of Miller Ferguson et al (17) Retrospective, n = 85 3
intracranial hypertension Mehta et al (18) 3
Retrospective, n = 22
Thresholds for cerebral Allen et al (19) Retrospective, n = 317 2
perfusion pressure Miller Ferguson et al (17) 3
Retrospective, n = 85
Vavilala et al (20) Retrospective, n = 236 3
Treatments
Hyperosmolar therapy Shein et al (21) Prospective, n = 16 2
Piper et al (22) Treatment series, n = 32 3
Webster et al (23) Retrospective, n = 58 3
Gonda et al (24) Retrospective, n = 48 traumatic brain injury 3
Analgesics, sedatives, and Welch et al (25) Treatment series, n = 31 3
neuromuscular blockade Shein et al (21) 3
Prospective, n = 16
Cerebrospinal fluid drainage Andrade et al (26) Treatment series, n = 58, n = 11 (younger than 17) 3
Seizure prophylaxis Liesemer et al (27) Retrospective, n = 54 moderate, n = 221 severe 3
Ventilation therapies No new studies
Temperature control/ Tasker et al (28, 30) Meta-analysis, n = 470 Fair quality
hypothermia Crompton et al (29, 31) Poor quality
Meta-analysis, n = 454
Adelson et al (32) RCT, n = 77 1
Beca et al (33) RCT, n = 50 2
Hutchinson et al (34) Retrospective (secondary analysis of 2008 RCT), n = 225 2
Empey et al (35) RCT, n = 19 3
Barbiturates Vavilala et al (20) Retrospective, n = 236 3
Mellion et al (36) Treatment series, n = 36 3
Decompressive craniectomy Pechmann et al (37) Treatment series, n = 12 3
Prasad et al (38) Treatment series, n = 71 3
Desgranges et al (39) Treatment series, n = 12 3
Khan et al (40) Treatment series, n = 25, 21 severe 3
Csokay et al (41) Treatment series, n = 8 3
Suarez et al (42) Treatment series, n = 14 3
Adamo et al (43) Treatment series, n = 7 3
Figaji et al (44) Treatment series, n = 12 3
Messing-Junger et al (45) Treatment series, n = 7 3
Nutrition Taha et al (46) Retrospective, n = 90 3
Corticosteroids No new studies
RCT = randomized controlled trial.
or management approach exists independent of other treat- therapy goals for children with severe traumatic brain injury-an interna-
tional study. Pediatr Crit Care Med 2013; 14:811–818
ments and approaches or independent of the ecology of the
6. Bell MJ, Adelson PD, Wisniewski SR; Investigators of the ADAPT
treatment setting. The design of meaningful and effective Study: Challenges and opportunities for pediatric severe TBI-review
future research must be consistent with this clinical reality. of the evidence and exploring a way forward. Childs Nerv Syst 2017;
2) Ongoing identification of new topics for investigation. As 33:1663–1667
our understanding of TBI and trauma improves, it is likely 7. Kurz JE, Poloyac SM, Abend NS, et al; Investigators for the Approaches
and Decisions in Acute Pediatric TBI Trial: Variation in anticonvulsant
new topics will need to be added to the Guidelines. The lit-
selection and electroencephalographic monitoring following severe
erature and ongoing trials need to be scanned regularly. It traumatic brain injury in children-understanding resource availability in
is important that the Guidelines reliably include what evi- sites participating in a comparative effectiveness study. Pediatr Crit
dence is available for new, emerging topics and treatments. Care Med 2016; 17:649–657
3) Consistency in data collection across studies. Future 8. Jha RM, Kochanek PM: Adding insight to injury: A new era in neu-
rotrauma. Lancet Neurol 2017; 16:578–580
research should emphasize consistency in data collection
9. Kochanek PM, Bell MJ: Tackling the challenges of clinical trials for
across research projects, such as utilization of the Common severe traumatic brain injury in children: Screening, phenotyping, and
Data Elements of the National Institutes of Health (60–63). adapting. Crit Care Med 2015; 43:1544–1546
10. Bennett TD, DeWitt PE, Greene TH, et al: Functional outcome after
It is important that the pediatric TBI research community intracranial pressure monitoring for children with severe traumatic
systematically address these questions by creating a prioritized brain injury. JAMA Pediatr 2017; 171:965–971
research agenda and advocating for additional high-quality 11. Alkhoury F, Kyriakides TC: Intracranial pressure monitoring in children
research that can populate the evidence base for future guidelines. with severe traumatic brain injury: National trauma data bank-based
review of outcomes. JAMA Surg 2014; 149:544–548
12. Bennett TD, Riva-Cambrin J, Keenan HT, et al: Variation in intracranial
CONCLUSIONS pressure monitoring and outcomes in pediatric traumatic brain injury.
Arch Pediatr Adolesc Med 2012; 166:641–647
The increase in the number of studies as well as the number of
13. Stippler M, Ortiz V, Adelson PD, et al: Brain tissue oxygen monitoring
class 2 studies and level II recommendations is encouraging. The after severe traumatic brain injury in children: Relationship to outcome
growth in the evidence base strengthens the utility of the evidence- and association with other clinical parameters. J Neurosurg Pediatr
based recommendations as a basis for local protocols, which can 2012; 10:383–391
incorporate consensus where evidence is still not available. How- 14. Figaji AA, Zwane E, Graham Fieggen A, et al: The effect of increased
inspired fraction of oxygen on brain tissue oxygen tension in children
ever, this update also underscores that much work remains to be with severe traumatic brain injury. Neurocrit Care 2010; 12:430–437
done if our goal is evidence-based treatment designed to improve 15. Bailey BM, Liesemer K, Statler KD, et al: Monitoring and prediction
outcomes for children who sustain severe TBI. of intracranial hypertension in pediatric traumatic brain injury: Clinical
factors and initial head computed tomography. J Trauma Acute Care
Surg 2012; 72:263–270
ACKNOWLEDGMENTS 16. Bata SC, Yung M: Role of routine repeat head imaging in paediatric
We would like to thank the following people at the Pacific traumatic brain injury. ANZ J Surg 2014; 84:438–441
Northwest Evidence-based Practice Center at Oregon Health 17. Miller Ferguson N, Shein SL, Kochanek PM, et al: Intracranial hyper-
tension and cerebral hypoperfusion in children with severe traumatic
& Science University for their invaluable assistance in produc- brain injury: Thresholds and burden in accidental and abusive insults.
ing this document: Roger Chou, MD, Elaine Graham, MLS, Pediatr Crit Care Med 2016; 17:444–450
Andrew Hamilton, MS, MLS, Hyon Hildebrant, BA, Shaun 18. Mehta A, Kochanek PM, Tyler-Kabara E, et al: Relationship of intracranial
Ramirez, MPH, Leah Williams, BS. We also thank Jamshid pressure and cerebral perfusion pressure with outcome in young children
after severe traumatic brain injury. Dev Neurosci 2010; 32:413–419
Ghajar, MD, PhD, from the Brain Trauma Foundation and
19. Allen BB, Chiu YL, Gerber LM, et al: Age-specific cerebral perfusion
Stanford University. pressure thresholds and survival in children and adolescents with
severe traumatic brain injury*. Pediatr Crit Care Med 2014; 15:62–70
20. Vavilala MS, Kernic MA, Wang J, et al; Pediatric Guideline Adherence
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